Arthroscopic knee surgery when over 50. Are there non-surgical options?

Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C

At our center we see a lot of patients who love to be active, play golf, tennis, pickleball. We also see patients who have demanding lines of work. Contractors, landscapers, jobs that require being on their feet all day. What these patients have in common is that they are entering middle age and they are starting to have some degenerative breakdowns in their knees.

What they also have in common is that they have reached a point that their knee braces, over-the-counter medications, ice packs and heating pads are not helping anymore. Even so, the morning or pre-activity workout will still include pre-emptive NSAIDs to keep swelling at bay and the knee brace to hold their knee together. When the knee brace no longer fits under work clothes, then sometime of sleeve or taping is used.

So this may be your story. You went to your doctor, got a referral for an orthopedist, had an x-ray, an MRI, some damage was seen, maybe it was an undescriptive type of damage, something was there and no one was really sure what it was or to what extent. You were prescribed stronger doses of the medications that you were already taking to see if that helps. But you are starting to think the NSAIDs are make you problem worse. You were sent to physical therapy and massage therapy to see if that helped.

Now you are at the point where you have to decide to:

a) Live with it until you can’t anymore.

b) Seek a surgical option.

c) Seek something more on the alternative, non-surgical side of medicine. Here your orthopedist may have even discussed stem cell therapy and platelet rich plasma therapy. We are going to discuss all these options below.

When I entered into my 50’s my knees started to give out on me. There went my golf game.

Here is a familiar story.

When I entered into my 50’s my knees started to give out on me. They started to become very painful and I had constant swelling. I was developing a bone on bone situation in my knees. I am an active guy, or I was. I used to play golf every second I could get myself out there. When I do play now, when my knees feel up to it, I have to use the cart because I can no longer walk the course. It is just not my knees anymore. It is also the weight I have been putting on. My doctors convinced me that if I had knee surgery, and I did, I had most of my meniscus removed last year, that the benefit would be reduced pain, and increase in my activity, and it would be easier for me to lose weight. Maybe that is what happens for other people. That is not what happened for me.

After the meniscus removal my knee hurt more, I became less active, I put on more weight and now my activity is reduced to what ever I can do in physical therapy as even everyday walking has become painful. Now I am being told to consider knee replacement. The knee replacement, so I am told, will reduce my pain and make me more active and I will be able to lose weight. Well that is why I had the arthroscopic surgery and it did not work out. Now I am exploring other options.

In our almost three decades of helping people with knee pain, this is the type of confusion we see in patients. What will help me? What will not help me? The treatments I thought would help did not. The things I am doing to try to stay healthy may be making me unhealthy.

We have a number of articles on our website that discuss topics of staying healthy trough knee pain. Here are some of them:

I do not want to do an annual knee surgery

So how do we have healthy individuals, maintaining weight, no time to slow down, staying active getting frequent knee surgeries? May be here is how:

I am very active, golf, tennis, out in the ocean a lot. Water and snow ski. Two years ago I tore my meniscus. Silly injury, all I did was jump off a stair. That was in my left knee. My surgeon told me all the years of activity were beginning to take their toll. I had arthroscopic surgery, the doctor took out a piece of my meniscus that could not be repaired and everything felt fine. Then I few months later, I did the same exact thing to my right knee. A silly injury, believe it or not demonstrating to someone how I hurt my left knee. I was scheduled for another meniscus surgery.

Now I am concerned that will I have to have a surgery every year? Taking out bits and pieces of my knee until there is nothing left? I am very healthy, almost 60 year old. I do not want to keep doing this until I need knee replacements.

Research: For many patients who are over 50, arthroscopic meniscus surgery should not be offered. Instead patients should continue with nonoperative management until total knee replacement is unavoidable.

From many years there has been a controversy as to whether arthroscopic knee surgery should even be offered to middle age patients. Some patients may get into that situation where they have had numerous surgeries.

In December 2020, surgeons published a paper in the medical journal Arthroscopy (1). In this paper the doctors traced arthroscopic knee surgical outcomes over a 20 years period in patients who had the knee surgery between the ages of 50 – 70. Part of the research was to see how many of these patients who had the arthroscopy, had to have a total knee replacement anyway.

Here are the learning points of this research:

Well maybe arthroscopic meniscus surgery can be offered for some.

Sometimes we will get an email from some one who will tell us: “I went to (a well known, leading medical center, one of the best in the world,) and they told me they would do a knee surgery, but they did not know what type to offer and once we will do the surgery we are not sure of the outcome, we will have to see if it helps.”

We do see many patients who were told that their meniscus surgery may or may not help. Ultimately the only way to know was to have the surgery and see how it turns out.

Here is a study that was in the August 2019 issue of The American journal of sports medicine.(2)

Here are the learning points:

Results: There were no meaningful differences in patient satisfaction or clinical outcomes between patients with traumatic and degenerative tears and no or mild osteoarthritis . Predictors of dissatisfaction with arthroscopic partial meniscectomy were female sex, obesity, and lateral meniscal tears. Our findings suggested that arthroscopic partial meniscectomy was an effective medium-term option to relieve pain and recover function in middle-aged patients with degenerative meniscal tears, without obvious osteoarthritis, and with failed prior physical therapy.

In other words, if you do not have degenerative arthritis developing, were not obese, had the meniscus tear on the outside, and were were a man. This surgery would be more successful for you a s a “medium-term option.” That is until your knee started to deteriorate further and you needed an “end-term option.” Knee replacement.

Let us point out again, many people have very successful arthroscopic partial meniscectomy procedures. These are the people that we do not see at our center. We see the people will less than successful outcomes.

Do people have an over expectation of what arthroscopic knee surgery can really do for their knee problem?

People in pain have a lot of whishes. They wish the pain will go away, they wish they can get back on with their lives, activity and work. They wish the surgery, or any treatment including the ones we offer, will work.

MRI Knee Meniscus

The middle-aged patient and meniscus surgery – surgeons cannot predict which patients will benefit and who will not benefit from meniscus surgery. Flipping a coin would work just as well.

In our companion article: Should I have meniscus surgery? Does arthroscopic meniscus surgery leads to knee replacement? We have more extensive discussions about realistic outcomes of arthroscopic knee surgery and non-surgical treatments for knee problems in the older patient. Here is a summary of portions of that article.

The question trying to be answered here is: “Will this surgery work for me?”

A March 2020 study in the British Journal of Sports Medicine (3) questioned whether experienced orthopedic surgeons could predict who would benefit from surgery for degenerative meniscus tears and who would not.

The researchers set up an experiment. Surgeons participating in this study were given 20 cases to examine. In each case, the surgeon was asked to predict the outcome of treatment for meniscal tears by arthroscopic partial meniscectomy and exercise therapy in middle-aged patients. The surgeons were also asked to predict the beneficial change in knee function in those patients they would recommend to surgery and those patients they would send to physical therapy or an exercise program.

The surgeons combined to examine and predict outcomes in 3880 knees. The results?

Here is a positive study on the benefits of meniscus surgery (4in the middle-aged patient: In this study, doctors said that an arthroscopic partial meniscectomy is a good option for a medial meniscal tear in late middle-aged adults. For the best success, you need a proper diagnosis and excellent surgical technique. If you follow these two rules all the patients could get good clinical results, HOWEVER, “there are some patients with motion restrictions in the early stage after the operation.” 

In other words, even if a patient received “a proper diagnosis and excellent surgical technique,” problems with motion restrictions in the knee developed early. Motion restrictions are probably not what a middle-aged patient is expecting as a result of their meniscus surgery.

Stem Cell Therapy, Platelet Rich Plasma Therapy and Prolotherapy

In this sections we are going to discuss the realistic expectation of what these three regenerative medicine techniques can do to help you avoid a surgery. These treatments will not benefit everyone. Our hope here is to present information to help understand the treatments.

For more information on the different types of injections for knee pain. Please see our article: What are the different types of knee injections for bone on bone knees

Stem cell therapy as a non-surgical alternative to arthroscopic knee surgery

Perhaps nothing is as misunderstood in the world of regenerative medicine injections as is misunderstood when it comes to stem cell therapy. Our website is filled with articles on stem cell treatments. We are going to present some summarized information as it relates to you.

I have no meniscus, will stem cell therapy grow one back?

NO. Stem cell therapy, as an injection in the doctor’s office, will not grow a meniscus from nothing. in our article Does stem cell therapy for knee meniscus tears and post-meniscectomy work?, we offer a lot of research, patient stories and clinical observations. To summarize that article here with learning points:

The reality of stem cell therapy

Over expectation of what stem cell therapy can do may lead to patient disappointment

The research on stem cell therapy for meniscus tears. Does it work or not?

At our center, we have seen bone marrow aspirate stem cell therapy help many people. There are many types of stem cell therapy including Amniotic, cord blood, placenta stem cell therapy. We DO NOT USE THESE PRODUCTS. This is explained in our article: Amniotic, cord blood, placenta stem cell therapy.

October 2020 research: Bone marrow-derived mesenchymal stem cells have the potential to help form meniscus tissue

An October 2020 study (5)  lead by the University of Alberta in Edmonton, Canada offered this observation in the journal Tissue Engineering (Part A). “Bone marrow-derived mesenchymal stem cells have the potential to form the mechanically responsive matrices of joint tissues, including the menisci of the knee joint.” Matrices are the scaffold-like structures that are created in the body for things like fingernails and cartilage to grow on.

In this study a comparison was made: Do bone marrow stem cells taken from the iliac crest (the wing of the pelvis) create meniscus matrices? Further, if they do, how do they compare with stem cells taken from meniscus fibrochondrocytes cells (cartilage cells) taken from meniscus tissue removed during a partial meniscectomy of non-osteoarthritic knees. The general results? Bone marrow-derived mesenchymal stem cells from the iliac crest produced better meniscus building block tissue better than meniscus tissue did.

Bone marrow aspirate – stem cell therapy and Prolotherapy

In our office, “Bone marrow aspirate” or stem cell therapy is used in conjunction with dextrose Prolotherapy. Prolotherapy is a non-surgical regenerative treatment that can stimulate natural healing repair in the knee. The goal of the treatment to rebuild tissue and provide stability to the knee. Stem cell therapy or Stem cell Prolotherapy is the combined use of your own harvested stem cells and dextrose Prolotherapy to treat the entire knee environment.

Not all meniscus tears and injuries (even those after meniscus surgery) require stem cell therapy to heal. We have documented in numerous studies that simple dextrose Prolotherapy has a 90% success rate in our office. However, for cases of the more advanced meniscus and related cartilage damage, our team of Prolotherapy practitioners may choose to use stem cell injections in combination with dextrose Prolotherapy to strengthen and stabilize the surrounding support structures of the knee.

Our published research on stem cell therapy combined with Prolotherapy

When we use bone marrow derived stem cells and Prolotherapy together:

Our 2014 study in the journal Clinical Medicine Insights. Arthritis and Musculoskeletal Disorders, (6) we examined 24 adult patients who had a diagnosis of radiographic osteoarthritis (this was degenerative knee diseases which was seen and documented on an MRI) and had visited our chronic pain clinic in 2009 for Prolotherapy treatment to relieve their chronic pain. The results of our study have shown that a combined bone marrow stem cell Prolotherapy treatment regimen of injections to painful sites in and around the knee provided pain relief and improved joint function.

Paving the way for stem cell therapy success with Prolotherapy treatments

In the simplest terms, Prolotherapy is the injection of sugar water into a damaged joint. Prolotherapy injections work to heal damaged joints by stimulating nature’s healing and regenerative processes through inflammation. Prolotherapy does so by causing a controlled, specifically targeted inflammation that helps grow new ligament and tendon tissue.

Stem cell therapy is an injection of your own harvested stem cells. Stem cell therapy is typically utilized when we need to “patch” holes in cartilage and stimulate bone. We explore this option in patients when there is a more advanced osteoarthritis and a recommendation to a joint replacement has been made or suggested. Realistic expectation of treatments success should be made during discussions with the providers office prior consultation.

Here are the case histories of this study:

Case history 1

Case history 2

Case history 3

In Comprehensive Prolotherapy, the knee joint instability is restored by repairing and regenerating tissue

We use non-surgical treatments for meniscus tears. We may use our Prolotherapy treatments and PRP. This is an in-office injection treatment. This video and the summary below is an introduction to our non-surgical treatments. It is presented by Danielle R. Steilen-Matias, MMS, PA-C.

Platelet Rich Plasma Therapy and Prolotherapy, which stimulates tendons, ligaments, and cartilage to heal, has many advantages over arthroscopy, which include:

Do you want to ask about your knees? Get help and information from our Caring Medical staff

1 Aprato A, Sordo L, Costantino A, Sabatini L, Barberis L, Testa D, Massè A. OUTCOMES AT TWENTY YEARS AFTER MENISCECTOMY IN PATIENTS AGED BETWEEN 50-70 YEARS. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2020 Dec 9. [Google Scholar]
2 Lizaur-Utrilla A, Miralles-Muñoz FA, Gonzalez-Parreño S, Lopez-Prats FA. Outcomes and patient satisfaction with arthroscopic partial meniscectomy for degenerative and traumatic tears in middle-aged patients with no or mild osteoarthritis. The American journal of sports medicine. 2019 Aug;47(10):2412-9. [Google Scholar]
3  van de Graaf VA, Bloembergen CH MD, Willigenburg NW PhD, et al. Can even experienced orthopaedic surgeons predict who will benefit from surgery when patients present with degenerative meniscal tears? A survey of 194 orthopaedic surgeons who made 3880 predictions. Br J Sports Med. 2020;54(6):354-359. doi:10.1136/bjsports-2019-100567  [Google Scholar]
4 Liu JS, Li ZY. Arthroscopic partial meniscectomy for medial meniscal tear in late middle-aged adults. Zhongguo gu shang= China journal of orthopaedics and traumatology. 2014 Aug;27(8):631-4. [Google Scholar]
5 Elkhenany HA, Szojka ARA, Mulet-Sierra A, Liang Y, Kunze M, Lan X, Sommerfeldt M, Jomha NM, Adesida AB. Bone Marrow Mesenchymal Stem Cell-Derived Tissues are Mechanically Superior to Meniscus Cells. Tissue Eng Part A. 2020 Oct 30. [Google Scholar].
6 Hauser RA, Orlofsky A. Regenerative injection therapy with whole bone marrow aspirate for degenerative joint disease: a case series. Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders. 2013 Jan;6:CMAMD-S10951. [Google Scholar]

 

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